“Victims of friendly fire,” time to “jump in the boat,” & misleading cancer advertising
Welcome to the RightCare Weekly, a newsletter that will help you stay on top of all the important news in the ongoing quest to move the U.S. health care system toward the right care. We’ll bring you the most important stories, news articles, and opinion pieces of the week, along with our interpretation of why they’re important and what they mean for patients, doctors, and communities.
Dr. David Newman, who was featured in last week’s roundup writing on statins, highlights an incredibly important paper by Drs. Harlan Krumholz and Allan Detsky assessing how hospitals can help patients avoid “post-hospital syndrome.” Krumholz has written before about how disruptive hospital care can be for patients – meaning even after they’ve gotten over their illness, sometimes patients need additional time to recover from the stress of a hospital stay. There are ways to avoid the problems patients experience after hospitalizations, often by simply making the hospital environment more humane. Allowing patients to wear their own clothes, improving hospital food, and avoiding unnecessary interference with patients’ sleep can all help avoid treating the hospital like a “battlefield,” where patients are too often “victims of friendly fire.”
In an interview with Vox’s Adrianna McIntyre, David Cutler, a former healthcare advisor to President Obama reflected on our understanding of value in the health care system. Cutler argues that lower health care costs will come from focusing on improving the quality of care and the value provided by the system. For example, Cutler notes that only 11 hospitals in Ontario are set up for open-heart surgery, while 60 hospitals can perform it in Pennsylvania (which has around the same population). The extra high-tech capacity in Pennsylvania costs a lot more to build and operate – but patients don’t do any better than in Ontario. There are similar examples throughout the system. Cutler also notes the importance of changes in the payment system, and worries about the current state of payment reform: rather than staying with “one foot on the dock [fee-for-service] and one in the boat,” “We’ve got to jump in the boat — let’s just do it.”
Paul Levy of the Not Running a Hospital blog brings us a great example of the culture of overuse in action, in summarizing a recent Annals of Internal Medicine article on the advertising strategies of cancer centers. The paper found that treatment was promoted far more often than screening or supportive services (88% as opposed to 18% and 13%, respectively), and that advertised therapies were described far more often than risks of treatment. Emotional appeals evoking hope for survival trumped evidence-based statements of which patients were likely to benefit, and disclaimers were rarely included. This isn’t a new phenomenon, either: misleading advertising in cancer screening and treatment is a recurring problem.
An article in the Upshot by Austin Frakt and Amitabh Chandra entitled “How to Pay for Only the Healthcare You Want” lays out an idea proposed by Professor Russell Korobkin in which health insurance plans are defined by the level of treatment they cover – from basic plans that cover highly cost-effective care like treatment for emergencies and accidents, genetic diseases, and preventative care, to others that cover evidence-based drugs and procedures, and therapies generally accepted by the medical community, and finally to plans that cover anything shown to be effective, and even experimental and unproven therapies. The different plans would charge progressively higher premiums based on the range of treatments. It raises a couple of interesting questions about how people think about their health insurance. The most powerful element of the proposal might just be to show people how much of their health insurance premium is currently going to treatments that aren’t rooted in evidence, or which haven’t shown benefit in any trial. Moreover, by acknowledging which therapies are unproven, it might be easier for patients to understand the real choices they’re making when they decide if experimental or unproven treatments are really worth the risk.
On the Wall Street Journal‘s “The Experts” blog, Dr. Robert Wachter says that Baby Boomers are “addicted to a ‘more is more’ philosophy when it comes to health care.” He points out that the “can do” attitude common in the United States tends to reinforce the notion that more medicine will make us feel better, regardless of our ills – but that attitude also papers over the harms of constant intervention. He closes wishing patients knew that “sometimes more is exactly what they need, while at other times the right answer–the one that will best ensure both their physical and their financial health–is to do less.”